Neurosurgery Pre-Op [1710] Patient Name MRN. General. Nursing. Case Request [ ] Case request operating room Scheduling/ADT, Scheduling/ADT [ ] Other
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1 Neurosurgery Pre-Op [1710] Patient Name MRN General Case Request [ ] Case request operating room Scheduling/ADT, Scheduling/ADT Inpatient Only Procedure (Single Response) ( ) Admit to Inpatient Diagnosis: Admitting Physician: Attending Physician: Level of Care: Patient Condition: Bed request comments: Certification: I certify that based on my best clinical judgment and the patient's condition as documented in the HP and progress notes, I expect that the patient will need hospital services for two or more midnights. Isolation Status [ ] Airborne isolation status Routine, Continuous, [ ] Contact isolation status Routine, Continuous, [ ] Droplet isolation status Routine, Continuous, [ ] Enteric isolation status Routine, Continuous, Precautions [ ] Aspiration precautions [ ] Fall precautions Increased observation level needed: [ ] Latex precautions [ ] Seizure precautions Increased observation level needed: Nursing Vital Signs [ ] Vital signs - T/P/R/BP (per unit protocol) Routine, Per unit protocol, Activity [ ] Strict bed rest Routine, Until discontinued, Starting S, [ ] Bed rest with bedside commode Routine, Until discontinued, Starting S Bathroom Privileges: with bedside commode [ ] Bed rest with bathroom privileges Routine, Until discontinued, Starting S Bathroom Privileges: with bathroom privileges [ ] Up with assistance Routine, Until discontinued, Starting S Specify: Up with assistance Printed on 5/11/2016 at 12:48 PM from POC environment Page 1 of 6
2 [ ] Up ad lib Routine, Until discontinued, Starting S Specify: Up ad lib [ ] Head of bed 30 degrees Routine, Until discontinued, Starting S Head of bed: 30 degrees [ ] Head of bed flat Routine, Until discontinued, Starting S Head of bed: flat Nursing [ ] Insert and Maintain Foley [ ] Insert Foley catheter Routine, Once Type: Size: Urinometer needed: 1) Remove Foley cath POD 1 or POD 2 and Document reason for not removing Foley. (Must be documented on POD 1 or POD 2), [ ] Foley Catheter Care Routine, Until discontinued, Starting S Orders: Maintain 1) Remove Foley cath POD 1 or POD 2 and Document reason for not removing Foley. (Must be documented on POD 1 or POD 2), [ ] Confirm NPO Status Routine, Until discontinued, Starting S, [ ] Pulse oximetry check Routine, Daily Current FIO2 or Room Air: On arrival to Pre-Op (Day Surgery), [ ] No anticoagulants INcluding UNfractionated heparin Routine, Until discontinued, Starting S, [ ] No anti-platelet agents INcluding aspirin Routine, Until discontinued, Starting S, Notify [ ] Notify Physician if current oral intake status could potentially delay procedure start time Routine, Until discontinued, Starting S, if current oral intake status could potentially delay procedure start time, Consent [ ] Complete Consent Form Routine, Once Consent For: Procedure: Diagnosis/Condition: Physician: Diet [ ] NPO Diet effective now, Starting S NPO: [ ] NPO-After Midnight Diet effective midnight, Starting S+1 at 12:01 AM NPO: [ ] NPO-Except meds Diet effective now, Starting S NPO: Except meds Printed on 5/11/2016 at 12:48 PM from POC environment Page 2 of 6
3 [ ] NPO after midnight except Meds Diet effective midnight, Starting S+1 at 12:01 AM NPO: Except meds IV Fluids Insert and Maintain IV [ ] Initiate and maintain IV [ ] Insert peripheral IV Routine, Once, [ ] sodium chloride 0.9 % flush 10 ml, intravenous, every 12 hours scheduled, [ ] sodium chloride 0.9 % flush 10 ml, intravenous, PRN, line care, IV Fluids (Single Response) ( ) lactated Ringer's infusion intravenous, continuous, ( ) sodium chloride 0.9 % infusion intravenous, continuous, ( ) sodium chloride 0.9 % with potassium chloride 20 meq/l intravenous, continuous, infusion ( ) dextrose 5 % and sodium chloride 0.45 % with intravenous, continuous, potassium chloride 20 meq/l infusion Medications Intrathecal Infusion Pumps (Single Response) ( ) Implanted Intrathecal Infusion Pump with Sodium Chloride 0.9 % intrathecal infusion Medication(s) delivered: Injectable saline [ ] sodium chloride 0.9 % infusion intrathecal, continuous, ( ) Implanted Intrathecal Infusion Pump with Baclofen 50 mcg/ml intrathecal infusion Medication(s) delivered: Low concentration baclofen [ ] baclofen (LIORESAL) 50 mcg/ml injection 50 mcg, intrathecal, continuous, ( ) Implanted Intrathecal Infusion Pump with Baclofen 500 mcg/ml intrathecal infusion Medication(s) delivered: High concentration baclofen [ ] baclofen (LIORESAL) 500 mcg/ml intrathecal injection intrathecal, continuous, ( ) Implanted Intrathecal Infusion Pump with morphine infusion Medication(s) delivered: Intrathecal morphine [ ] morphine (PF) (INFUMORPH) in sodium chloride 0.9% intrathecal, continuous, intrathecal injection ( ) Implanted Intrathecal Infusion Pump with CUSTOM intrathecal infusion Medication(s) delivered: Custom cocktail transferred to new pump [ ] Custom intrathecal infusion - Specify intrathecal, continuous, Printed on 5/11/2016 at 12:48 PM from POC environment Page 3 of 6
4 Labs Labs STAT [ ] Type and screen STAT For 1 Occurrences, [ ] CBC and differential STAT For 1 Occurrences, [ ] Partial thromboplastin time STAT For 1 Occurrences, [ ] Prothrombin time with INR STAT For 1 Occurrences, [ ] Basic metabolic panel STAT For 1 Occurrences, [ ] Comprehensive metabolic panel STAT For 1 Occurrences, [ ] Platelet function P2Y12 STAT For 1 Occurrences, [ ] Platelet function analysis STAT For 1 Occurrences, [ ] Bedside Glucose and Notify "And" Linked Panel [ ] Bedside glucose Routine, Once, [ ] Notify Physician of bedside blood glucose LESS than 70 Routine, Until discontinued, Starting S, mg/dl and GREATER than 180 mg/dl [ ] Calcium STAT For 1 Occurrences, [ ] Magnesium STAT For 1 Occurrences, [ ] Phosphorus STAT For 1 Occurrences, [ ] Pregnancy, urine STAT For 1 Occurrences, [ ] Urine culture screen STAT For 1 Occurrences, Urine, Labs - AM [ ] Type and screen AM draw For 1 Occurrences, [ ] CBC and differential AM draw For 1 Occurrences, [ ] Basic metabolic panel AM draw For 1 Occurrences, [ ] Comprehensive metabolic panel AM draw For 1 Occurrences, [ ] Partial thromboplastin time AM draw For 1 Occurrences, [ ] Prothrombin time with INR AM draw For 1 Occurrences, [ ] Platelet function P2Y12 AM draw For 1 Occurrences, [ ] Platelet function analysis AM draw For 1 Occurrences, [ ] Calcium AM draw For 1 Occurrences, [ ] Magnesium AM draw For 1 Occurrences, [ ] Phosphorus AM draw For 1 Occurrences, [ ] Pregnancy, urine AM draw For 1 Occurrences, [ ] Urine culture screen AM draw For 1 Occurrences, Urine, Cardiology Cardiology [ ] ECG Pre/Post Op Routine, Once Clinical Indications: Interpreting Physician: [ ] Echocardiogram complete w contrast and 3D if needed Routine, 1 time imaging, Imaging X-ray [ ] Chest 2 Vw Routine, 1 time imaging For 1, [ ] Chest 1 Vw Routine, 1 time imaging For 1, Other Studies Printed on 5/11/2016 at 12:48 PM from POC environment Page 4 of 6
5 Other Diagnostic Studies [ ] Intraoperative monitoring Routine, Once Procedure: O.R. Location: Modality: Consults Ancillary Consults [ ] Consult to Case Management Consult Reason: [ ] Consult to Social Work Reason for Consult: [ ] Consult PT eval and treat Special Instructions: Weight Bearing Status: [ ] Consult PT wound care Routine, Once Special Instructions: Location of Wound? [ ] Consult OT eval and treat Special Instructions: Weight Bearing Status: [ ] Consult to Nutrition Services Reason For Consult? [ ] Consult to Spiritual Care Reason for consult? [ ] Consult to Speech Language Pathology Routine, Once Reason for SLP? [ ] Consult to Wound Ostomy Care nurse Reason for consult: Reason for consult: Reason for consult: Reason for consult: Consult for NPWT: [ ] Consult to Respiratory Therapy Reason for Consult? Lab Draw [ ] Type and screen Once, Blood Products - Adult [ ] Adult Blood Administration - Red Blood Cells [ ] Prepare RBC Routine Special Requirements: [ ] Transfuse RBC Routine [ ] Adult Blood Administration - Platelets [ ] Prepare platelet pheresis Routine Special Requirements: Printed on 5/11/2016 at 12:48 PM from POC environment Page 5 of 6
6 [ ] Transfuse platelets Routine [ ] Adult Blood Administration - Fresh Frozen Plasma [ ] Prepare fresh frozen plasma Routine [ ] Transfuse fresh frozen plasma Routine [ ] Adult Blood Administration - Cryoprecipitate [ ] Prepare cryoprecipitate Routine [ ] Transfuse cryoprecipitate Routine IV Fluids [ ] sodium chloride 0.9 % infusion 250 ml, intravenous, at 30 ml/hr, continuous, Administer with blood [ ] sodium chloride 0.9 % infusion 500 ml, intravenous, at 30 ml/hr, continuous, Administer with blood Medications [ ] acetaminophen (TYLENOL) tablet oral, once, For 1 Doses, [ ] diphenhydramine (BENADRYL) capsule 25 mg, oral, once, For 1 Doses, [ ] diphenhydramine (BENADRYL) injection 25 mg, intravenous, once, For 1 Doses, [ ] hydrocortisone sodium succinate (PF) (Solu-CORTEF) 100 mg, intravenous, once, For 1 Doses, injection [ ] furosemide (LASIX) injection 20 mg, intravenous, once, For 1 Doses, [ ] furosemide (LASIX) tablet oral, once, For 1 Doses, Physician Signature Date Printed on 5/11/2016 at 12:48 PM from POC environment Page 6 of 6
Physician Orders PEDIATRIC: LEB Oral Maxillofacial Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: LEB Oral Maxillofacial Postop Phase, When to Initiate: LEB Oral Maxillofacial Post Op Phase Admission/Transfer/Discharge
IR Central Venous Access [ ] Pre Procedure
![IR Central Venous Access [ ] Pre Procedure](/thumbs/90/104119758.jpg "IR Central Venous Access [ ] Pre Procedure")
IR Central Venous Access [1050200001] Pre Procedure Case Request/Scheduling Procedure Enter IR Case Request if not already completed (All hospitals except Grant Medical Center) [ ] Case Request IR Lab
ALL orders are active unless: 1. Order is manually lined through to inactivate 2. Orders with check boxes ( ) are unchecked DRUG AND TREATMENT ORDERS
DRUG AND TREATMENT Available at: BMC-B BMC-D BMC-N BMC-S Vital Signs Vital Signs Q4H (DEF)* Q2H Q1H Vital Signs Orthostatic Activity Activity Bedrest, for 12 hours then Up ad lib (DEF)* Bedrest, for 24
ADMIT DIABETIC KETOACIDOSIS (DKA) PLAN - Phase: Begin Immediately/Emergency Center
- Phase: Begin Immediately/Emergency Center Weight PHYSICIAN S Allergies Admit/Discharge/Transfer Patient Status Requested Location: MICU, Pt Status: Inpatient (LOS > 2 midnights) Requested Location: 5E
Routine, Every 2 hours, Starting today, If temperature greater than 38.5 C initiate Evaluation for Possible Sepsis Physician Order #829
Height Weight Allergies General Vital Signs [X] Frequent vital signs Indication: Q15 minutes x (# of occurrences): 4 Q30 minutes x (# of occurrences): 4 Q1 hour x (# of occurrences): Q2 hours x (# of occurrences):
Bariatric Surgery Post Op Day Version 2 Approved 11/13/2017
Patient Name: Diagnosis: Allergies with reaction type: Bariatric Surgery Post Op Day Version 2 Approved 11/13/2017 Diagnosis Preferred Location/Unit Surgical ICU Code Status: Full Code Activity Ambulate
DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available at: BMC-B BMC-D BMC-N BMC-S Vital Signs Vital Signs Q4H (DEF)* Q2H Q1H Vital Signs Orthostatic Activity Activity Bedrest, for 12 hours then Up ad lib (DEF)* Bedrest, for 24
RITUXIMAB RHEUMATOLOGY VASCULITIS
. PHYSICIAN (Patient Sticker) ORDER SET : CDH 208-237 Approved - Page 1 of 5 Patient: DOB: Gender: Patient Phone #: Height: Weight: Diagnosis: ICD-10 Code: Treatment Start Date: Provider Facility Name:
PEDIATRIC SPINE SURGERY POST-OP PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Patient Activity Bedrest Maintain Surgical Drain Maintain JP Drain, Measure Output q12h, and PRN Convert IV to INT when tolerating
Physician Orders PEDIATRIC: LEB DKA Diabetes Mellitus Admit Plan
Initiate Orders Phase Non Categorized R Powerplan Open Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: Admit DKA Two-Bag Calculations Phase, When to Initiate: Initiate Powerplan Phase Phase:
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Non Categorized SUB Sub Phase (SUB)* Non Categorized Quality Measures STK Diet ED NPO Until Bedside Swallow Screen passed Nursing Orders Activate Code Stroke Vital Signs Q15MINS Int
Physician Orders PEDIATRIC: : LEB ED Trauma (Major) Plan
LEB ED Standing Orders Trauma (Major) Ph Non Categorized Criteria: Patients between 0-18 years of age that present with a Major Trauma that meet LeBonheur Trauma stat or Trauma Alert Guidelines.(NOTE)*
Gabapentin Research Pain Study for Ortho Total Knee Replacement Post-Op Plan - PACU Ortho Phase
Total Knee Replacement Post-Op Plan - PACU Ortho Phase Diagnosis Weight Allergies Admit/Discharge/Transfer Patient Status Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights) Patient Condition
PICU ADMIT DKA PLAN - Phase: Begin Immediately
- Phase: Begin Immediately Diagnosis Weight Allergies Admit/Discharge/Transfer Patient Status Requested Location: PICU, Pt Status: Inpatient (LOS > 2 midnights) Requested Location: PICU, Pt Status: Observation
Acute Stroke with Alteplase Administration Order Set
Review Due Date: 2017 October PATIENT CARE DERS Weight: Adverse Reactions or Intolerances Drug No Yes (list) Food No Yes (list) _ Latex No Yes Admission Admit to Neurology service: Dr. Critical Care Diagnosis:
Physician Orders ADULT: Asthma and Bronchitis Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase, Phase: Asthma and Bronchitis Phase, When to Initiate: Asthma and Bronchitis Phase Non Categorized Problem: Asthma Problem:
Bariatric Surgery Post Op Plan PACU Phase
Bariatric Surgery Post Op Plan PACU Phase PHYSICIAN S Weight Allergies Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Code Status
Standard Precautions Droplet Precautions Standard Precautions Contact Precautions Droplet Precautions Standard Precautions Neutropenic Precautions
Unique Plan Description: Neurosurgery Subarachnoid Hemorrhage Admission Adult Plan Selection Display: Neurosurgery Subarachnoid Hemorrhage Admission Adult PlanType: Medical Version: 10 Begin Effective
ST. DOMINIC-JACKSON MEMORIAL HOSPITAL JACKSON, MISSISSIPPI
Date & Time Post-Op Inpatient General Orthopedic Page 1 of 5 Pharmacy Mnemonic: POIGOP1 1. Admit as inpatient to Dr. 2.Diagnosis: 3.Admit to PACU and then to floor ICU 4.Radiology: AP Pelvis in PACU AP
Physician Orders ADULT: Kidney-Panc/PancTransplant Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase T;N, Phase: Kidney-Panc/Panc Transp Post Op Phase, When to Initiate: Kidney-Panc/Panc Transp Post Op Phase Vital Signs Vital
ALL orders are active unless: 1. Order is manually lined through to inactivate 2. Orders with check boxes ( ) are unchecked DRUG AND TREATMENT ORDERS
Available at: ALL Adult Facilities Non Categorized SUB Protocol(SUB)* SUB Protocol Lab Orders(SUB)* ED Rainbow Tubes(SUB)* ***Reminder: Order ED Rainbow Tubes (SUB) as a separate form*** Nursing Orders
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
Available at ALL facilities Non Categorized SUB ED Chest Pain: STEMI Protocol(SUB)* SUB ED Chest Pain: STEMI Protocol Lab Orders(SUB)* ED Rainbow Tubes(SUB)* ***Reminder: Order ED Rainbow Tubes (SUB) as
ORTHO TOTAL KNEE REPLACEMENT POST-OP PLAN - Phase: PACU Ortho Phase
- Phase: PACU Ortho Phase PHYSICIAN S Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Patient Condition Acuity Level Floor Status Acuity Level Critical Acuity Level Intermediate
Physician Orders ADULT Order Set: Respiratory Failure Orders
[R] = will be ordered Height: cm Weight: kg Allergies: [ ] No known allergies [ ]Medication allergy(s): [ ] Latex allergy [ ]Other: Admission/Transfer/Discharge [ ] Patient Status Initial Inpatient Attending
Physician Orders ADULT: Renal Transplant Admit Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase, Phase: Renal Transplant Admit Phase, When to Initiate: Renal Transplant Admit Phase Non Categorized Initiate Powerplan Phase,
IDPH ESF-8 Plan: Pediatric and Neonatal Surge Annex Sample Pediatric Admission Orders 2015
Purpose: To provide guidance to practitioners caring for pediatric patients who need inpatient hospital care during a disaster. Disclaimer: This guideline is not meant to be all inclusive, replace an existing
Physician Orders LEB PICU Status Epilepticus Plan. [ ] No known allergies
![Physician Orders LEB PICU Status Epilepticus Plan. [ ] No known allergies](/thumbs/80/82315048.jpg "Physician Orders LEB PICU Status Epilepticus Plan. [ ] No known allergies")
Height: cm Weight: kg Allergies: [ ] No known allergies [ ] Initiate Powerplan Phase T;N, Phase: LEB PICU Admit Phase Admission/Transfer/Discharge [ ] Admit Patient to Dr. [ ] Admit Status: [ ] Inpatient
* * FORM REV. 02/2019 Page 1 of 4. TNKASE (tenecteplase) / ACUTE STEMI ORDERS SCHEDULED MEDICATIONS:
1. Is this a CMS inpatient only procedure? Yes, admit as inpatient, proceed to # 3 No, proceed to # 2 2. Do you expect that the patient s condition will require a hospital stay that will cross two midnights
LIFEGIFT BRAIN DEATH PLAN
Diagnosis Weight Allergies Admit/Discharge/Transfer ***THIS PLAN IS TO BE ED ONLY ON THE LIFEGIFT ENCOUNTER, WITH DR LIFEGIFT AS THE ATTENDING*** Patient Status Pt Status: Inpatient (Inpatient only procedure)
Initials * Page 1 of 6. (place patient label here) Patient Name: Diagnosis: Allergies with reaction type:
Patient Name: Diagnosis: Allergies with reaction type: Orthopedic Upper Ext Post Op Version 3 4/20/17 Patient Placement General Diagnosis/Procedure: Preferred Location/Unit Ortho/Neuro General Medical
Diagnosis: Allergies with reaction type:
Patient Name: Diagnosis: Allergies with reaction type: ICU Stroke-Ischemic S/P tpa Version 2 5/29/14 This order set is designed to be used with an admission set or for a patient already admitted Nursing
PEDIATRIC SPINE SURGERY POST-OP PLAN - Phase: Pediatric Spine Surgery General Orders
- Phase: Pediatric Spine Surgery General Orders PHYSICIAN S Diagnosis Weight Allergies Patient Care Patient Activity Bedrest Maintain Surgical Drain Maintain JP Drain, Measure Output q12h, and PRN Convert
PEDIATRIC LIFEGIFT BRAIN DEATH PLAN
PHYSICIAN S Diagnosis Weight Allergies Admit/Discharge/Transfer THIS PLAN IS TO BE ED ONLY ON THE LIFEGIFT ENCOUNTER, WITH DR LIFEGIFT AS THE ATTENDING. Patient Status Pt Status: Inpatient (Inpatient only
Physician Orders PEDIATRIC: LEB Eating Disorder Admit Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: LEB Eating Disorder Admit Phase, When to Initiate: When patient arrives to unit LEB Eating Disorder Admit Phase Admission/Transfer/Discharge
Diagnosis: Allergies:
Patient Name: Diagnosis: Allergies: ICU Sepsis Version 5 1/11/17 This order set must be used with an admission order set if patient not already admitted. Nursing Orders Verify that cultures have been obtained
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available at: BMC-B BMC-D BMC-N BMC-S Condition/Status Patient Status Inpatient Patient Status: Inpatient, Level of Care: Med/Surg without Telemetry (1) (DEF)* Patient Status: Inpatient,
PHYSICIAN ORDERS Diagnosis
PICU PROCEDURE PLAN PHYSICIAN S Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Patient Care
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available ONLY at: BMC-B BMC-D BMC-N BMC-S Nursing Orders Communication Order If CVP unavailable, administer fluid boluses every 30 minutes except monitor O2 requirements Comments: Every
General. Code Status (Single Response) ( ) Full Code Details ( ) Full code - unverified Details ( ) DNRCC Allow additional therapies?
Post Operative Above and Below Knee Amputation Admission [3041300028] Consider adding Insulin Adult -- Subcutaneous Insulin and Hypoglycemia Management [3041300000] General Admission (Single Response)
Zzbeacon,Zayna [MR ]
![Zzbeacon,Zayna [MR ]](/thumbs/89/98203205.jpg "Zzbeacon,Zayna [MR ]")
AALL1131-DS INDUCTION HR-ALL, DAYS 1-14 Properties Cycle 1 9/27/2012 through 10/10/2012 (14 days), Planned Day 1, Cycle 1 Planned for 9/27/2012 Release Labs CBC and differential Release Release Comprehensive
ADULT POST NEUROLOGIC INTERVENTION ORDERS 2 of 4
9 Actual 9 Estimated DOWNTIME INTERVENTION 1 of 4 Weight kg 9 Actual 9 Estimated Height cm ALLERGIES: REFER TO ALLERGY PROFILE/ POWERCHART Admit to Dr.: Bed Type: Dx: ( ) Check, circle and/or fill in all
UMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
PHYSICIAN S Diagnosis Weight Allergies Admit/Discharge/Transfer Patient Status Requested Location: NICU, Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Pt Status: Inpatient
Physician Orders ADULT: Ortho Total Joint Plan
Initiate Orders Phase Non Categorized R Powerplan Open Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: Ortho Total Joint Preop Phase, When to Initiate: Other-See Special Instructions, initiate
Gabapentin Research Pain Study for Ortho Total Knee Replacement Post Op Plan PACU Ortho Phase
Total Knee Replacement Post Op Plan PACU Ortho Phase PHYSICIAN S Weight Allergies DETAILS Admit/Discharge/Transfer Request Patient Bed Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights),
Physician s Order Form. Physician s Order Form. Telemetry/Progressive Care Orders. Continued on next page. >>>>>>> Continued on next page.
DATE: TIME: DATE TIME INTRAVENOS FLID and MEDICATION Status: Admit to Telemetry Admit to Progressive Care nit Transfer to Progressive Care nit Note: Discontinue Previous Orders Transfer to Telemetry nit
Assessment. Consults & Referrals
University of Virginia Health System Clinical Pathway: Whipple Enhanced Recovery After () LOS: 4-5 days Date of Origin/Revision: June 29, 2016/September 6, 2017/January 31, 2018 : SAS : : : D1 D2 D 3/
Physician Orders ADULT: Sickle Cell Inpatient Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: Sickle Cell Inpatient Phase, When to Initiate: When patient arrives to unit Sickle Cell Inpatient Phase Admission/Transfer/Discharge
BARIATRIC SURGERY POST-OP PLAN - Phase: PACU Phase
- Phase: PACU Phase Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Pt Status: Inpatient (Inpatient
Physician Orders. PED Endocrine General Admit Plan [X or R] = will be ordered unless marked out. [ ] No known allergies
![Physician Orders. PED Endocrine General Admit Plan [X or R] = will be ordered unless marked out. [ ] No known allergies](/thumbs/90/102440183.jpg "Physician Orders. PED Endocrine General Admit Plan [X or R] = will be ordered unless marked out. [ ] No known allergies")
Height: cm Weight: kg Allergies: [ ] No known allergies [ ] Initiate Powerplan Phase T;N, Phase:PED Endo General Admit Phase Admission/Transfer/Discharge [ ] Admit Patient to Dr. Admit Status: [ ] Inpatient
ENT THYROIDECTOMY/PARATHYROIDECTOMY POST OP ADMIT PLAN - Phase: Begin Immediately/PACU
- Phase: Begin Immediately/PACU Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Pt Status:
Therapeutic Hypothermia for Post Cardiac Arrest Plan Initial Orders
Arrest Plan Initial Orders Weight Allergies Therapeutic Hypothermia Guidelines ***Required to continue with ordering Plan.*** Strict Intake and Output q1h, throughout cooling and re warming. Set Up for
Physician Orders ADULT: Atrial Fib/Flutter Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: Atrial Fib/Flutter Phase, When to Initiate: Atrial Fib/Flutter Phase Non Categorized Problem: Atrial fibrillation Problem:
PHYSICIAN ORDER SET : Patient: DOB: Gender: Patient Phone #: Height: Weight:
. (Patient Sticker) CDH 208-203 Approved 2/18 - Page 1 of 5 Patient: DOB: Gender: Patient Phone #: Height: Weight: Diagnosis: ICD-10 Code: Treatment Start Date: Provider Facility Name: Ordering Provider:
Physician Orders PEDIATRIC: LEB NEURO Epilepsy Monitoring Unit Admit Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: LEB Neuro Epilepsy Monitoring Unit Admit Phase, When to Initiate: LEB Neuro Epilepsy Monitor Unit Admit Phase Non Categorized
Hip Hemiarthroplasty Post Op Version 2 4/20/17
Patient Name: Diagnosis: Allergies with reaction type: Hip Hemiarthroplasty Post Op Version 2 4/20/17 Patient Placement General Diagnosis/Procedure: Preferred Location/Unit Ortho/Neuro PCU ICU General
Zzbeacon,Zayna [MR ]
![Zzbeacon,Zayna [MR ]](/thumbs/86/93872827.jpg "Zzbeacon,Zayna [MR ]")
AALL1131 INTERIM MAINTENANCE, HR-ALL, ARM B, HD MTX Properties Cycle 1 9/27/2012 through 11/28/2012 (63 days), Planned Day 1, Cycle 1 Planned for 9/27/2012 Release CBC and differential Release Release
GENERAL SURGICAL ADULT POST-OPERATIVE ORDERS 1 of 4
down ADULT POST-OPERATIVE 1 of 4 9 Actual 9 Estimated Patient ID Area Weight kg 9 Actual 9 Estimated Height cm ALLERGIES: REFER TO ALLERGY PROFILE/ POWERCHART Admit to: Post Anesthesia Care Unit (PACU),
Orthopedic Admission Hip Fracture Version 2 1/25/2017
Patient Name: Initial each page and Sign/Date/Time last page Diagnosis: Allergies with reaction type: Orthopedic Admission Hip Fracture Version 2 1/25/2017 Patient Placement Patient Status If the physician
Physician Orders ADULT: Head and Neck Postoperative Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase, Phase: Head and Neck Postoperative Phase, When to Initiate: Head and Neck Post Operative Phase, Monitor and Record T,P,R,BP,
Pediatric Intensive Care Unit (PICU) Pediatric Diabetic Ketoacidosis (DKA) Admission Order Set
Discontinue all previous orders Weight: kg DKA admit order set is for initial management Ongoing management required based on frequent reassessment of TFI, fluid balance and lab results. Admit to PICU
LYSIS OF ADHESIONS POST-OP PLAN - Phase: PACU Phase
- Phase: PACU Phase PHYSICIAN S Diagnosis Weight Allergies Communication Place Device at Bedside Confirm there are 3 x Aliquots of 0.2% Ropivacaine. 2 x Medfusion Infusion pumps. Confirm 3 x PF Aliquots
ST. DOMINIC-JACKSON MEMORIAL HOSPITAL JACKSON, MISSISSIPPI
Date & Time TAVR Pre-Op Admission Clinical Pathway Page 1 of 3 1. Admit as INPATIENT to Dr.. For Surgery Today or Tomorrow 3. Diagnosis: 4. Allergies: Pharmacy Mnemonic: PRETAVR 5. Vital signs on arrival.
Physician Orders. LEB NICU Sepsis Plan [X or R] = will be ordered unless marked out.
![Physician Orders. LEB NICU Sepsis Plan [X or R] = will be ordered unless marked out.](/thumbs/77/75931338.jpg "Physician Orders. LEB NICU Sepsis Plan [X or R] = will be ordered unless marked out.")
Height: cm Weight: kg Allergies: [ ] No known allergies [ ] Latex allergy [ ]Other: [ ] Initiate Powerplan Phase, Phase: LEB NICU Sepsis Phase Admission/Transfer/Discharge [ ] Patient Status Initial Inpatient
Physician Orders ADULT: Acute MI/Acute Coronary Syndrome Adult Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: Acute MI/Acute Coronary Syndrome Adult Phase, When to Initiate: Acute MI/Acute Coronary Syndrome Adlt Phase Non Categorized
Total Hip Replacement Post Op Version 4 4/20/17
Patient Name: Diagnosis: Allergies with reaction type: Total Hip Replacement Post Op Version 4 4/20/17 Patient Placement General Diagnosis/Procedure: Preferred Location/Unit Ortho/Neuro General Medical
CBC with Differential. PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Non Categorized SUB ED Snakebite Protocol (SUB)* Non Categorized ***(NOTE)*** This plan is designed to be used as part of a larger plan, not independently. Please do NOT order individually.
Pediatric Outpatient Surgery Plan - Diagnostic/Pre-Op Orders
Pediatric Outpatient Surgery Plan - Diagnostic/Pre-Op Orders Diagnosis Weight PHYSICIAN S Allergies Admit/Discharge/Transfer Request for Outpatient Services Location: Outpatient Surgery Communication Misc
Physician Orders PEDIATRIC: LEB Stroke Admit Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: LEB Stroke Admit Phase. When to Initiate: LEB Stroke Admit Phase Admission/Transfer/Discharge Patient Status Initial
(31189) Hypothermia Initiation Phase One
Hypothermia Initiation Phase One Diagnosis Allergies For hypothermia tracking purposes only. Please do not uncheck.- Required Cardiac Emergency Tracking For hypothermia tracking purposes only. Consults
1. Attending Physician: Dr Syn Pager: Cell: Co-Morbidities:
BARIATRIC SURGERY IMMEDIATE POST-OP PLAN (Includes Post Op Day 1) Denotes order requirement Antibiotic administered in the OR at: 1. Attending Physician: Dr Syn Pager: 740-6545 Cell: 438-9415 2. To remain
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available at: ALL Adult Facilities Non Categorized SUB Protocol(SUB)* SUB Protocol Lab Orders(SUB)* ED Rainbow Tubes(SUB)* ***Reminder: Order ED Rainbow Tubes (SUB) as a separate form***
INPATIENT INTERVENTIONAL RADIOLOGY PLAN - Phase: Pre-Procedure Orders
- Phase: Pre-Procedure Orders DETAILS Patient Care Obtain Consent If one is not present on chart today. Vital Signs Per Policy Insert Peripheral Line T;N, Start IV on right side If left radial access is
GENERAL MEDICINE PLAN
GENERAL MEDICINE PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom
Physician Orders ADULT: PCI Post Procedure Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: PCI Post Procedure Phase, When to Initiate: Initiate Powerplan Phase Phase: Post Cath/PCI Hydration Protocol Phase,
Diagnosis: Allergies with reaction type:
Patient Name: Initial each page and Sign/Date/Time last page Diagnosis: Allergies with reaction type: ICU Admission Comprehensive Version 3 4/10/17 Patient Placement Patient Status If the physician cannot
Emergency Department Chest Pain, Suspected Cardiac Adult Order Set
Form Title Form Number Chest Pain, Suspected Cardiac Adult Order Set 20746 2018, Alberta Health Services, CKCM This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT *****ALSO ORDER SUB ACUTE DKA IV FLUIDS REGIMEN & SUB ACUTE ELECTROLYTE REPLACEMENT on separate forms ***** Condition/Status For purpose of this DKA Regimen, DKA is considered clear
LONG TERM CARE FACILITY ADMIT ORDERS
Page 1 of 7 LONG TERM CARE FACILITY ADMIT ORDERS ADMISSION: Admit patient to Skilled Nursing Facility: Admit patient to Acute Rehabilitation Facility: Admit patient to Subacute Rehabilitation Facility:
OB Well Baby Nursery Admission (Term) [ ] For specialty focused order sets for your patient, refer to: General
![OB Well Baby Nursery Admission (Term) [ ] For specialty focused order sets for your patient, refer to: General](/thumbs/85/91909911.jpg "OB Well Baby Nursery Admission (Term) [ ] For specialty focused order sets for your patient, refer to: General")
OB Well Baby Nursery Admission (Term) [3040000234] For specialty focused order sets for your patient, refer to: 3040000424 Neonatal Circumcision Order Set 3040000522 Neonatal Herpes Viral Order Set 3040000524
DONATION AFTER CARDIAC DEATH PLAN
DONATION AFTER CARDIAC DEATH PLAN Diagnosis Weight Allergies Patient Care Core Body Temperature Monitoring Maintain body temp 96-99 degrees Farenheit. Utilize Hyper/Hypothermia blanket prn Insert Gastric
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
Available at: BMC-B BMC-D BMC-N BMC-S Activity Activity Bedrest with BRP, with assistance at nurse's discretion (DEF)* Ambulate with Assistance Diet Communication Order Patient to remain NPO while in PACU
ALL orders are active unless: 1. Order is manually lined through to inactivate 2. Orders with check boxes ( ) are unchecked
Available at: BMC-B BMC-D BMC-N BMC-S Condition/Status ***(NOTE)***For purpose of this DKA Regimen, DKA is considered clear only when the CO2 is GREATER than 18 meq/l and the anion gap is LESS than 12
Physician Orders PEDIATRIC: LEB ED Hx of DKA with Hyperglycemia Plan
LEB ED Triage Hx of DKA w Hyperglycemia Non Categorized Criteria for use: Patients less than 18 years of age with known or suspected Diabetes Mellitus and blood glucose greater than 300mg/dL.(NOTE)* Vital
ENT THYROIDECTOMY/PARATHYROIDECTOMY POST OP PLAN - Phase: Begin Immediately/PACU
- Phase: Begin Immediately/PACU PHYSICIAN S Diagnosis Weight Allergies Laboratory Calcium Level STAT Outpatient/PACU, T;N PTH Intact STAT Outpatient/PACU, T;N 1 of 7 - Phase: When Patient Arrives to Room
GENERAL SURGERY POST-OP PLAN
GENERAL SURGERY POST-OP PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available at: ALL Adult Facilities Non Categorized SUB ED Abdominal Pain Protocol(SUB)* ***The above subphase is available at the end of the plan*** SUB ED Abdominal Pain Protocol Lab
(Page 1 of 5) Diagnosis: Procedure: Right Total Knee Replacement Unicompartmental Knee Left Total Hip Revision Total Shoulder
(Page 1 of 5) Allergies/Sensitivities/Reactions: Height: Inches cm Weight: Kg Pounds = Automatic = Physician s option, Check off to Order Diagnosis: Procedure: Right Total Knee Replacement Unicompartmental
Physician Orders PEDIATRIC: LEB NEURO SURG Surgical Spine Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: LEB Neuro Surg Spine Postop Phase, When to Initiate: LEB Neuro Surgical Spine Post Op Phase Admission/Transfer/Discharge
Physician Orders PEDIATRIC: LEB Kidney Transplant Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: LEB Kidney Transplant Post Op Phase, When to Initiate: LEB Kidney Transplant Post Op Phase Admission/Transfer/Discharge
Consent Laboratory Transfuse RBC
Peds Blood Product Infusion Order Set (386) [386] Blood product review will be performed unless exclusion criteria met. MD: Please note if transfusion giv en outside of parameter, please justify use in
1. Diagnosis: 2. Co-Morbidities: Allergies: NKDA Allergic to:
BMT NON -HODGKIN S LYMPHOMA Autologous Stem Cell Transplant Routine Plan 1. Diagnosis: 2. Co-Morbidities: Allergies: NKDA Allergic to: 3. Attending Physician: Notify on call Resident/Fellow Consult: Social
DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Acute Diabetic Ketoacidosis Condition/Status ***(NOTE)*** For purpose of this DKA Regimen, DKA is considered clear only when the CO2 is GREATER than 18 meq/l and the anion gap is LESS
GENERAL SURGERY PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom Privileges
IV Acetaminophen Pain Study for Neurosurgery Post Op Non ICU Admit Plan Begin Immediately/PACU
Post Op Non ICU Admit Plan Begin Immediately/PACU PHYSICIAN S Weight Allergies Admit/Discharge/Transfer Request Patient Bed Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights) Patient Condition
INFLIXIMAB RHEUMATOLOGY LOAD DOSE (SCHEDULE WEEKS 0, 2, 6)
. INFLIXIMAB RHEUMATOLOGY LOAD DOSE (SCHEDULE CDH 208-211 Approved 2/18 - Page 1 of 5 Patient: DOB: Gender: Patient Phone #: Height: Weight: Diagnosis: ICD-10 Code: Treatment Start Date: Provider Facility
ADMIT STROKE NEUROINTERVENTION PLAN - Phase: Begin Immediately
- Phase: Begin Immediately PHYSICIAN S Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Pt
Physician Orders ADULT: ANES Enhanced Recovery After Surgery (ERAS) Plan
Initiate Orders Phase Non Categorized R Powerplan Open Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: Anes (ERAS) Pre-insertion Phase, When to Initiate: Other-See Special Instructions,
Sample. Affix patient label within this box.
Instructions for completing orders: Determine PRAM Clinical Score as per the Alberta Acute Childhood Asthma Pathway for Emergent/Urgent Care and select orders based on PRAM Score. Custom orders can be
ADMIT GENERAL MEDICINE PLAN - Phase: Begin Immediately
- Phase: Begin Immediately Weight PHYSICIAN S Allergies Admit/Discharge/Transfer Patient Status Patient Condition Acuity Level Floor Status Acuity Level Critical Acuity Level Intermediate Continuous Telemetry